Health inspection·December 4, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and/or implement a care plan to meet the needs for one of three sampled residents (Resident 1). Resident 1 was assessed at risk for elopement (leaving an institution without notice or permission) and required a wander guard (a system used to alarm staff of a potential elopement of a resident) to be applied. This deficient practice resulted a wander guard not being applied to Resident 1 and Resident 1 eloping from the facility on 11/26/2023. This deficient practice had the potential for Resident 1 to sustain an injury and/or death. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses including dementia (a progressive loss of memory), unsteadiness on feet, and anxiety (extreme worry). During a review of Resident 1's Minimum Data Set ([MDS]) a standard assessment and care screening tool), dated 11/10/2023, the MDS indicated Resident 1's cognitive (the ability to think, reason, and understood) skills for daily decision-making were severely impaired. During a review of Resident 1's Elopement Risk Evaluation, dated 11/6/2023, the Elopement Risk Evaluation indicated Resident 1 was ambulatory with an assisted device, had intermittent (on again, off again) confusion, received medications that increase restlessness and agitation and had a history of elopement for the last six months. The Elopement Risk Evaluation indicated Resident 1 scored an 18 for elopement (A score of 10 or higher is considered at risk for elopement/wandering). The Elopement Risk Evaluation indicated to apply a wander guard to Resident 1. During a review of Resident 1's Change of Condition (COC) dated 11/26/2023 and timed at 8:30 a.m., the COC indicated Resident 1 was missing at 8:30 a.m., a search for Resident 1 was initiated and Resident 1 was found next door to the facility at a local business. During a review of the Care Plan section of Resident 1's clinical records, the Care Plan section indicated there was no care plan developed related to Resident 1's at risk assessment for elopement. During a concurrent interview and record review on 12/4/2023 at 10:07 a.m., Resident 1's MDS and Elopement risk evaluation was reviewed with the MDS nurse confirmed and stated Resident 1 was assessed (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 055457 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Intercommunity Healthcare & Rehabilitation Center 12627 Studebaker Road Norwalk, CA 90650 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)